Patient Centered Medical Homes: Removing Barriers for Underserved Populations

A Research Brief by: Guadalupe Cervantes

GCDiabetes is a national health issue, in which African Americans are disproportionality affected. African Americans are 1.6 times more likely to develop type 2 diabetes and this number is seen to increase to 3 times more likely in 2020. In order to combat this health issue we must remove barriers for this population. One way to do so is by implementing a patient centered medical home (PCMH) model.

The African American population in the United States is 12.63%, and within Wayne County it is 39.31%. According to the Uniform Data System report submitted to Health Resources and Services Administration, 10.54% of all patients at the Detroit Community Health Connection (DCHC) have diabetes. This number is significantly different from that of the community needs assessment in which over 75% percent of DCH patients were reported to have diabetes. This huge discrepancy between official federal reports and community based reports leads to towards prevalent health issues going unseen. In turn, many barriers to these unseen health issues go unaddressed. Some of the known barriers include: lack of type 2 diabetes specific knowledge, poor self-management skills, and poor motivation to make lifestyle behavior changes.

Studies have showed that a PCMH models have been effectively utilized to help reduce barriers to healthcare. It is based upon six core principles: team-based care and practice organization, knowing and managing your patients, patient-centered access and continuity, care management and support, care coordination and care transitions, and performance measurement and quality improvement. These in turn result in reduce healthcare costs and improve patient care. Healthcare services are centralized in one location; thus remove barriers such as time and transportation.

With diabetes as the seventh leading cause of death in the United States, affecting about 9.4% of the population, it is crucial to take measure to address this public health issue. Recent studies have show PCMH models to have higher clinical improvements in several areas. It has improved clinical health outcomes by 32.6%, increased preventive health behaviors by 13.7%, and improved diabetes self-management by 12.0%. Additionally, PCMHs were seen to decrease hemoglobin A1C scores by 0.55% to 1.23%. One of the ways in which PCMHs have been successful in improving their health outcomes was through their utilization of a community needs assessment.

Community needs assessments (CNA) are required by non-profit organizations, such as federally qualified health centers (FQHC), in order to get funding from the government. If CNAs are done effectively, it would greatly benefit to the community which the FQHC serves. CNAs are designed to provide a snapshot of the current health issues and existing resources available in a given space. They help enact policy change, systems change, and environmental change. Additionally, CNAs gather culturally relevant responses which helps direct appropriate resources to a certain population. Moreso, they help build trust within the community. I urge everyone to utilize a CNA to help attain PCMH status, so that the services are tailored to the specific population.

I want to thank Detroit Community Health Connection for allowing me to conduct a community needs assessment at their site, as well as Dr.Jade Burns who had helped me put together and analyze the data.